Marriage as a perceived panacea to mental illness in India: Reality check.

Marriage is a consensual and contractual relationship recognized by law. In India, there is a tremendous social and cultural pressure to marry. It is of paramount importance to discuss the relationship between marriage and mental illness in Indian scenario as marriage is perceived to be a panacea to mental illness by many. This review aims to explore whether marriage contributes to mental-health problems; whether it has a protective role; what effect it has on pre-existing mental illnesses and its outcome in major mental illnesses.

INTRODUCTION

Marriage, as defined by “The Oxford Dictionary” is a formal union of man and woman, by which they become husband and wife, i.e., it is a consensual and contractual relationship recognized by law. It is a social commitment with multiple emotional, social and occupational demands. Marriage is a socially acceptable way to satisfy the basic human need for sexual gratification. It thus forms the basis for procreation and building up of family. Other reasons for marriage could be legal, emotional, economic, spiritual and religious.[12] Marriage is an important institution in human society and particularly so in Eastern countries, including India. In India, it is almost compulsory for every individual to marry and “settle down.” Not being married is considered a stigma, particularly in case of women whereas being married translates into elevation in social status. Marriages in India have certain distinctive features viz.

It is usually an arranged relation between two families with little scope for personal choices.[2]

There exists patriarchal ideology and the husband is considered head of the family and breadwinner.[2]

Women have social pressure to accept a position subservient to males, to control their sexual impulses and to subordinate their personal preferences to the needs of the family and kin group.[3]

There is a strong social and moral compulsion to continue the relationship despite facing difficulties/problems in the marriage. Divorce is frowned upon in the traditional Indian society.

The relationship between marriage and mental health can be explored in several ways. Few important dimensions to this issue are as follows:

Marriage as a stressful life event which can lead to development of mental-health problems.

Effect of marriage on mental health of men and women in the direction of protecting them against mental disorders.

Effect of marriage on pre-existing mental illness, e.g., Psychoses, alcohol use disorders.

Outcome of marriage in major psychiatric disorders like schizophrenia.

CAN MARRIAGE CAUSE MENTAL HEALTH PROBLEMS?

Marriage may be stressful for vulnerable people, which may lead to development of mental-health problems. Major mental-health disorders may be the cause or effect of marital discord.[1] Several studies have shown that marital stress is associated with a range of psychiatric diagnoses.[4] Certain personality traits and disorders like dependence, passiveness, aggression, histrionicity, paranoia and obsession, especially when aggression is a marked feature, have a high incidence of severe marital discord.[5]

When compared to well-adjusted couples, divorce seeking couples have a high psychiatric morbidity, with more neurotic traits.[1] Studies in male neurotics showed that inability of wife to escape from husband's constant neurotic behavior may contribute to her marital tension. Eventually separate outlook of both spouses may lead to independent and separate activities and further increase conflicts and gradual alienation.[67] Specific situations related to married life-like anorgasmia, impotence, discovery of extramarital affair, problems with children, an announcement of intent to divorce can be the major trigger to psychological problems.[1] Studies show greater distress among married women as compared to married men. It may be because of multiple factors, which result in psychological, social and biological stress in women viz. more responsibilities in taking care of the family, adjusting to a new family, pregnancy, childbirth, motherhood, etc.[1]

DOES MARRIAGE PROTECT?

Studies show that married men have a statistically significant delay (1-2 years) in onset of psychotic symptoms in schizophrenic illness, when compared with single men.[8] Married men are found to have the lowest rate of depression, as compared to divorced/separated men in whom rates were highest. Similar findings were seen in women in the Epidemiologic Catchment Area Study study(ECA).[9] In the National Survey of mental health and well-being of adults in Australia (1997), it was found that when a range of types of mental disorders are considered, marriage reduces the risk of mental disorders for both men and women (mood disorders, anxiety disorders, drug and alcohol use disorders).[10]

Data exists to support the fact that there is an association between marriage and lower alcohol consumption. However, there is evidence also that heavy drinking adversely impacts marital quality and stability and that there is increased consumption in response to transition to divorce.

Marriages, particularly when reinforced by children, significantly lessen the risks of suicide. Suicide rate is 11/100000 for married persons and double for those never married/single.[1] Word of caution however, exists. Marital and family problems can be important stressors leading to suicidal behavior, especially in case of married women, for whom in the traditional Indian social fabric, separation/divorce is not a very feasible alternative to problems such as marital discord, dowry demands and ill-treatment/cruelty by in-laws in a joint family structure.

The potential of marriage to reduce certain kinds of mental-health problems probably owes itself to the beneficial effects it confers in terms of increasing personal and social support. Marriage adds to social status and may decrease stigma.

EFFECT OF MARRIAGE ON PRE-EXISTING MENTAL ILLNESSES

In the presence of mental illness, if marriage is done under pressure, there exists a strong possibility of deterioration of mental condition. This is particularly true in case of female psychotic patients in India. Various stressors described as being responsible for exacerbations/relapse of illness are uncertainty of marriage being fixed-up, dowry-related issues, moving to a new home, difficulty in continuing necessary medications and having required follow-ups with the psychiatrist, stress of first sexual experience, pregnancy and childbirth.[2] Expressed emotions in the spouse's family may be high, which can worsen the course of illness and predispose to relapses. The situation becomes worse for the woman in Indian society as she has exited her existing social supports to move to her husband's household. Higher psychiatric morbidity exists after childbirth, particularly in areas of functional psychoses and depressive illness.[11]

In India, general perception is that men married to mentally ill women do not suffer as much as women married to mentally ill men, as the men or their families have the advantage of pocketing the dowry and then going in for a speedy divorce. Most of the women married to mentally ill men, however, get sparse support from their own family and they remain stuck in a difficult situation due to their dependence on the male spouse for reasons of social, financial and personal security and/or for the sake of children.

It is important to remember that most patients with mental illness with appropriate psychiatric treatment improve to the extent that they can pursue their studies and have a career, get married and continue with their marriage with an acceptable degree of functioning.

OUTCOME OF MARRIAGE IN MAJOR PSYCHIATRIC DISORDERS

Many studies demonstrate that psychiatric patients have higher rates of marital discord, separation and divorce.[5] Marriage is a social process requiring certain social abilities for it to be successful. Schizophrenia, which can lead to a reduction of such abilities, has been associated with lower marital rates and increased chances of adverse marital outcome.

Thara et al. however, found a fairly high marital rate of 70% in their cohort of first-onset schizophrenic patients, probably because of high rate of marriages and relative early age at marriage in India. The high marital rates, presence of children, shorter duration of illness at inclusion, presence of auditory hallucinations at intake were all associated with a good marital outcome. Being unemployed, experiencing a drop in socio-economic level and the presence of flat affect and self-neglect for a prolonged period were associated with a poor marital outcome.[12]

Women in Indian community are less likely to get mental health care, as having a mentally ill woman in the family is in itself a cause of stigma and social ridicule. Married mentally ill women are more likely to be sent back to their natal homes, abandoned, deserted or divorced. After separation, the burden of caring for the mentally ill woman almost invariably has to be borne by the aging parents. The woman herself faces social isolation and compounded stigma of mental illness and separation/divorce. In fact, Thara et al. found in their study that the stigma of being separated/divorced was more acutely felt by families and patients than that of the mental illness per se.[12]

In case of women, after marriage, an early relapse causes mistrust and suspicion in the family of the spouse, which in turn, jeopardizes the success of the marriage and the outcome of the illness. A psychotic episode after childbirth or several years of marriage are however, viewed more favorably and thus does not always result in separation/divorce.[1314] In schizophrenia, it is found that rates of fertility and reproduction are low.[1]

In alcohol addiction, higher rate of divorce is seen in heavy drinkers probably due to a high incidence of domestic violence to the tune of 60-80%.[15] Family problems that are likely to co-occur with alcohol problems include violence, marital conflict, infidelity, jealousy, economic insecurity, divorce and fetal alcohol effect.[16]

Numerous researchers have reported a strong association between marital problems and depression.[1718] Marital dissatisfaction was uniquely related to major depression for women and dysthymia for men, even after controlling for comorbid disorders.[19]

A landmark study by McLeod (1994) used a general population survey to compare perceived marital quality among couples in which one, both, or neither spouse met criteria for one of three anxiety disorders: (a) phobic disorder (b) generalized anxiety disorder or (c) panic disorder. McLeod found that the relationship between anxiety disorders and marital distress is moderated by the gender of the person with the problem, the type of anxiety disorder, whether the partner also has an anxiety disorder, and whose perception is assessed (the sufferer or the partner). More specifically, phobias in men were associated with lower marital quality being reported by both the men and their wives, but phobias in women did not appear to have a disruptive effect on perceived marital quality as reported by the phobic women or their husbands. In contrast, panic disorder in either men or women was associated with lower marital quality reported by both the sufferer and his or her spouse. Generalized anxiety disorder in women was associated with poorer marital functioning as reported by women, but not by their male partners, whereas husbands’ GAD was not associated with poorer marital functioning being reported by either spouse.[20]

CONCLUSION

To sum up, the relation between marriage and mental illness is indeed a very complex and multi-faceted one. Besides each influencing the outcome of the other, the matter also has legal and moral dimensions associated with it. Rao et al. have compiled an excellent review on marriage, mental health and Indian Legislation, which provides a comprehensive insight into the associated legal aspects of the matter.[1] The predicament faced by the treating psychiatrist in counseling mentally ill patients and families about prospects of marriage will be diminished to a great extent by the guidelines on marriage and mental health issues, which are being developed by the specialty section on women's mental health of the Indian Psychiatric Society. A further ramification of the issue of marriage and mental health, which needs extensive review and study, is the effect on the emotional and mental well-being of the children born of marriages where one or both partners suffer from mental disorders.